What is the Reasonable Useful Lifetime of a Prostheses?

Medicare establishes a Reasonable Useful Lifetime (RUL) for all O&P items. The RUL is used to determine how often the device may need to be replaced. A common misperception is a three-year RUL for prosthetic devices. However, according to the Local Coverage Determination (LCD) there is not an RUL for prostheses.

A prosthetic device may be replaced when:

• It is beyond repair
• It is out of warranty and costs to repair exceed 60% of Medicare allowable
• There are significant physiological changes in the patient’s condition.

Any claim involving the replacement of a major prostheses (foot, ankle, knee, socket) must have a signed physician's order and medical record documentation supporting the need for the replacement. The treating physician must detail the reason for replacement, such as:

• Significant changes in the patient's condition.
• Changes in the residual limb.
• Functional need changes
• The device is beyond repair.
• Repairs exceed 60 % of the cost of the replacement.
• The prosthesis is lost or stolen.

What does this mean for you?

When your patient needs a new prostheses or socket, make sure the patient has seen a treating physician recently. Ask the physician for detailed notes outlining the reason for replacement, the patient's functional level, and the continued need of the device. Create a new Standard Written Order (SWO) for the physician to sign.

If a patient has a device that is three years old or older, you are not able to automatically provide a new device. You must show the continued need, the reason the current device can no longer be used, and substantiate the claim with corroborating documentation.

When billing the item, use the associated HCPCS codes with the LT or RT modifier, K level modifier, and the RA modifier. RA indicates this is a replacement device.

More information about replacements can be found in the Lower Limb Prostheses LCD/Policy Article L33787/A52496.